Inspection on 23/08/05 for Tansley House

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tansley House 17/11/08

Tansley House 03/12/07

Tansley House 06/12/06

Tansley House 26/01/06

Tansley House 03/03/05

Tansley House 27/09/04

Tansley House 17/09/03

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Tansley House Church Street Tansley Matlock Derbyshire, DE4 5FE Lead Inspector Eileen McHale Unannounced 23 August 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tansley House Address Church Street, Tansley, Matlock, Derbyshire, DE4 5FE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) (01629) 580404 Mr Alan Baranowski Mr Steve Lomax Mrs Janet Baranowski Acting Manager – Beverley Windle Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Plus Three (3) Day Care Places Date of last inspection 3 March 2005 Brief Description of the Service: Tansley House is a well established care home registered for 20 elderly residents who require personal care only. The home provides pleasant ,homeely accommodation in 18 single rooms and one shared room. In practice the home usually accommodates 19 residents with the shared room being used if required by a married couple. There is a choice of lounges, a separate dining area and use of the garden. The home is situated in the centre of Tansley village. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. On the day of the inspection. A tour of the building was completed. The inspector spoke in some detail to 5 residents and more briefly to the majority of residents in the home. She tracked 3 care plans and examined two staff files. Discussion took place with the manager and two other staff members. What the service does well: What has improved since the last inspection? What they could do better: The home had some outstanding items from a previous inspection, including the provision of fly screens on the kitchen window and risk assessments on radiators with high surface temperatures. These would pose a risk to residents and were made subject to immediate requirements. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,6 Assessments were in place for residents but not all of their medical conditions were reflected within these assessments. EVIDENCE: The day to day needs of service users had been assessed and for some residents, care managers had produced assessments and care plans. The assessments did in one instance include specific conditions, the significance of which was unknown to the manager and staff. The implications of these conditions for the care of the resident were not identified within the assessment. Information within the assessment, which indicated that residents were self-medicating, had not been changed when the residents ceased managing their own medication. It was noted that the assessed needs of one resident included a diagnosis of Alzheimer’s disease but the manager indicated that at the present time the needs of the resident were not high and could be met within the home. In another instance referral had been made for a nursing assessment. The home did not provide intermediate care. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The health and personal care needs of residents were met to their satisfaction, in spite of the absence of care plans for some of them. EVIDENCE: Although assessments were in place for all residents these did not include risk assessments on moving and handling, tissue viability, nutritional risk assessments nor risk assessments on the risk of falls for all residents. The case files of some residents more recently admitted were examined and in two instances no care plans had been produced. Daily records were maintained including records of visits by GPs and contacts with other health professionals. These records indicated that prompt assistance was sought for the health care needs of service users including dental, chiropody and hearing services. The manager indicated that work was underway to ensure that care plans would be produced for all residents and those specific processes for reporting and recording would be established within a few weeks. Residents confirmed that if they were not well the home would call the doctor. They also confirmed that their privacy was maintained when they received personal care . Staff were said to respond quickly if a resident used the alarm call to summon help. All residents confirmed that they were very satisfied with Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 10 the standard of care in the home and felt that they were well treated by the members of staff who were helpful and pleasant. Although there was evidence that residents had managed their own medication, this was said not to be the case at the time of the inspection. The home had the monitored dosage system of medication. Photographs were in place on medication records for some residents. Staff administering medication had received training from the pharmacist who supplied the home. Records of medication were well maintained. The home had facilities for storing and recording controlled drugs but at the time of the inspection Temazepam was not being treated as a controlled drug Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Residents in the home exercised choice of lifestyle, diet and family contact and expressed satisfaction with the choices available. EVIDENCE: Residents reported that they were very settled in the home. When asked about the range of activities available, their answers reflected their preferences, with some indicating that they had no interest in activities. From those residents with an interest it was reported that occasional outings were available, that people from the Chapel visited the home to lead singing and that entertainers sometimes visited the home. The library service provided books for residents and exercises were available. Planned activities were on display in the home and records were maintained. Residents who spoke to the inspector indicated that they maintained contact with their families. The home had a four-week rotating menu, which was varied and incorporated choice. Fish was offered weekly, salad monthly, as a number of residents didn’t like it. Hot teas were available and an alternative tea menu was available. Residents confirmed that meals were very good and they had a choice of an alternative. The dining room was spacious and well presented. At the time of the inspection it was apparent that fly screens had not been fitted to the kitchen window as required by the Environmental Health Officer. This was outstanding from the previous inspection and was made subject to an Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 12 urgent requirement. It was noted also that the kitchen floor required attention as the covering was damaged. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home offers people the facility to complain and staff were aware of adult protection procedures. EVIDENCE: The home provided a box where residents or their families might put complaints or commendations. Since the last inspection no complaints had been recorded. Residents indicated that they would complain if they were not satisfied with anything in the home. The manager reported that all staff had received training on adult protection at the Winding Wheel in Chesterfield provided by external trainers. She had undertaken the 2-day course provided by Derbyshire County Council. No adult protection had been made to the Social Services Department although they had dealt with some financial matters on behalf of residents. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 Although the home was in general clean and well maintained areas affecting the safety of residents had been neglected. EVIDENCE: The home was maintained to a good standard of repair and décor, although the first floor corridor had received some wheelchair damage and the manager reported that it was high priority for redecoration. It was apparent that there was ongoing redecoration and refurbishment. However it was noted that a requirement from the last inspection to undertake risk assessments on radiators and ensure resident safety by ensuring the surfaces were maintained at a low temperature had not been completed. This was made subject to an immediate requirement. Access within the home was good with a shaft lift being made available and access to seating in the garden was by steps from the lounge and ramped access from the side of the home. The home was maintained to a clean and hygienic condition. Discussion took place with the manager on the avoidance of shared soap bars in bathrooms and toilets to reduce the risk of cross infection. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 15 Residents reported that the laundry operated to a good standard. Their appearance supported this view. The laundry was equipped with two washers. However the laundry had no sluice and a sink was used which was not appropriately plumber to take solids. The manager could not confirm that the washers met disinfection standards. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The home was adequately staffed but evidence of proper recruitment was not maintained. EVIDENCE: The rota provides for at least three staff members on duty in the morning and two in the afternoon. At night there is one waking staff member and an additional member of staff sleeping in the home.. The manager indicated that she had access to the Residential Forum standards for staffing. The manager worked mostly in the week. The home employed in addition one senor care staff and 5 care staff who worked days. One night staff also worked some days. Adequate catering and domestic staff were provided. Two staff files were examined included that of the most recently appointed staff member. In both cases there was a completed application form, which included information on previous qualifications and experience. It was noted that photocopies of previous certificates were not held on file. In both instances CRB checks had been requested but the more recently employed staff member was employed for a trial period on the basis of a POVA first check and the CRB check and references were still awaited. The home did not have all records required in Schedule 4 and an immediate requirement was made. For the more established staff member there was evidence of completed induction. A staff member confirmed that she had received induction training and training in moving and handling, food hygiene, infection control and the Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 17 administration of drugs. Most staff working in the home had NVQ training and this was offered to new recruits. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,35,36 EVIDENCE: Since the last inspection the current manager had been registered. She indicated areas of work that she had undertaken and had clear priorities for the near future. She indicated that residents held their own monies and that the home did not hold either monies or valuables on behalf of residents. Staff confirmed that supervision was provided as needed. Records showed that formal supervision was provided twice a year. Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x 3 3 x x Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Timescale for action 15(1) The manager must ensure that 31October all residents accommodated have 2005 a care plan outlining how their needs will be met, which is developed in consultation with the resident and/or their representative. 13(2) The manager must ensure that 31 October the recording and safekeeping of 2005 Temazepam complies with practice as outlined in the document The Administration and Control of medicines in Care Homes and Childrens Services. 16(2)(j) the home must ensure that all Immediate matters identified by the requiremen Environmental Health Officer are t attended to. 13(4)(a)(c Risk assessments must be Immediate ) carried out on radiators. Covers requiremen must be provided or low surface t. temperature radiators installed to ensure residents safety. 23(2)(k) The home should provide a 31 sluice or sluicing washer. December 2005 18(1)(a) All documentation identified in Immediate Schedule 4 must be made Requireme available on staff files. nt. Regulation Requirement 2. 9 3. 15 4. 19 5. 6. 26 29 Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 3 3 Good Practice Recommendations The manager should ensure that information is sought on the implications for a service user of any diagnosed medical condition. The manager should ensure that any resident with a diagnosis of dementia is made aware that the home is not registered to provide care for residents with dementia and it may be necessary to ask the resident to seek an alternative placement should their condition deteriorate. The registered person should ensure that the kitchen floor covering is maintained to a good condition. The manager should keep under review her systems of staff supervision and seek to meet the frequency levels within the National Minimum Standards. 3. 4. 15 36 Tansley House C52 C02 S20103 Tansley House V246384 230805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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